Mental Health Consultation

For centuries, healers had little understanding of disease and lacked the technologies we now know are necessary for the treatment and cure of many diseases. Physicians had few medications, and surgery was only a last resort. In fact, the most important tool for healing was the relationship between the physician and the patient. It is well known that social connectedness enhances health in both direct and indirect ways: directly regulating many biological functions, decreasing anxiety, providing opportunities for new information, and fostering alternative behaviors. Clinical wisdom holds that both the reality-based elements of the physician–patient relationship – in modern times referred to as the working alliance or the therapeutic alliance – and the fantasy-based elements of that relationship affect the patient’s pain, suffering, and recovery from illness. Historically, often the physician’s only interventions were reassuring patients, providing knowledge about the patient’s disease, accepting the patient’s feelings of distress as normal, and maximizing the patient’s hope for the future. Although these interventions, based on wisdom and intuition, are no longer the only tools available to the physician, they continue to be an important part of the physician’s and particularly the psychiatrist’s therapeutic armamentarium. Such nonspecific aspects of cure are often thought to be mystical or mysterious. In fact, in biological studies, they are recognized as the placebo effect. Oddly, these effects of interpersonal relationships are both one of the prized and one of the most denigrated aspects of all of medicine. Yet, as clinicians, we all strive to alleviate our patients’ pain and suffering and return them to health as soon as possible with whatever tools may help. Many well-designed studies show that 20–30% of subjects respond to the placebo condition. Recent studies show that analgesic placebo has similar neural mechanisms to opioid analgesia (Petrovic et al., 2002). The problem with placebos is not whether they work but that we do not understand how they work and, therefore, we do not have control over their effects. As a physician, one strives to maximize one’s interpersonal healing effects and, in this way as well as with other healing tools, increase the chances of our patients’ relief from pain and of recovery. The physician–patient relationship includes specific roles and motivations. These form the core ingredients of the healing process. In its most generic form, the physician–patient chapter Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 32 The Psychiatric Interview relationship is defined by the coming together of an expert and a help seeker to identify, understand, and solve the problems of the help seeker. The patient is motivated by the desire and hope for assistance and relief from pain, and the physician has an interest in people and a desire to help. Caring about and paying attention to a patient’s suffering can yield remarkable therapeutic dividends. More than one attending physician has been reminded of this when a patient deferred making a treatment decision until he or she was able to consult with “my doctor”, who turned out to be the medical student. In today’s technology-driven medicine, the importance and complexity of the physician–patient interaction are often overlooked. The amount of information the medical student or resident must learn frequently takes precedence over learning the fine points of helping the patient relax sufficiently to provide a thorough history or to allow the physician to palpate a painful abdomen. Talking with patients and understanding the intricacies of the physician–patient relationship may be given little formal attention in the medical school curriculum. Even so, medical students, residents, and staff physicians recognize, often with awe, the skill of the senior physician who uncovers the lost piece of history, motivates the patient who had given up hope, or is able to talk to the distressed family without increasing their sense of hopelessness or fear. The relationship between the physician and the patient is essential to the healing of many patients, perhaps particularly so for many psychiatric patients. The physician who can skillfully recognize the patient’s half-hidden comment that he or she has not been taking the prescribed medication, perhaps hidden because of feelings of shame, anger, or denial, is better able to ensure long-term compliance with medication as well as to motivate the patient to stay in treatment. Regardless of the type of treatment – medication, biofeedback, hospitalization, psychotherapy, or the rearrangement of the demands and responsibilities in the patient’s life – the relationship with the physician is critical to therapeutic outcome. Modern medicine emphasizes a specific role for the physician in the relationship with the patient. In many Western countries, the patient comes for help with a specific problem, and the doctor’s office staff secures permission from a third-party payer for the doctor to conduct a particular treatment, a prescribed intervention, which will take a specified amount of time. Decades ago, when the doctor was neighbor, advisor, and friend to the patient and routinely invited to important family events in the patient’s life such as weddings of children, and when doctors routinely cared for more than one generation of the same family, the physician typically assumed that he or she would be a source of strength and assistance to the patient throughout the cycle of life. This meant more than curing a specific disease or relieving a specific pain. While today’s patients may not consciously expect that the physician’s influence and healing powers will take many forms in a complex interpersonal relationship, human nature is still the same, and patients still want from their doctors many nonspecific forms of emotional support that can promote a sense of well-being and better health. Though modern doctors may feel a great deal of time pressure to see many patients each day and to focus narrowly their healing efforts, the physician must also be sensitive to the many needs of patients, who believe that the physician is possessed of wisdom and understanding. Sensitivity to such desires and needs will promote effective medical care in all specialties, with all patients. A view that such patients are unusually needy and demanding will not serve the cause of effective medical care. Finally, in today’s mobile and geographically evermore united world, the importance of recognizing the needs of patients from parts of the world other than that of the physician’s is a challenge to the practitioner. The physician must be open to the limitations of his or her Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 2 • Physician–Patient Relationship 33 knowledge of the expectations, beliefs, and likely behavior of patients from different cultures, nations, religions, and ethnic and socioeconomic backgrounds. The physician must recognize this challenge and, one hopes, embrace it with enthusiasm. It can make the practice of medicine a more exciting experience (Clinical Vignette 1). The physician–patient relationship is also a source of information for the physician. The way the patient relates to the physician can help the physician understand the problems the patient is experiencing in her or his interpersonal relationships. The nature of the physician–patient relationship can also provide information about relationships in the patient’s childhood family, in which interpersonal patterns are first learned. With this information, the physician can  better understand the patient’s experience, promote cooperation between the patient and those who care for her or him, and teach the patient new behavioral strategies in an empathic manner, understanding the patient’s subjective perspective, that is, feelings, thoughts, and behaviors. These clinical vignettes illustrate that the physician–patient relationship is composed of both the reality-based component (the working alliance or therapeutic alliance) and the fantasy-based component (the transference) derived from the patient’s patterns of interpersonal behavior learned in childhood. These may maximize or limit the patient’s sense of reassurance, available information, feelings of comfort, and sense of hope. In this way, the nonspecific curative aspects of the physician–patient relationship may be enhanced or diminished (Clinical Vignettes 2 and 3). Clinical Vignette 2 Somewhat different was the situation of a 30-year-old male patient who developed chronic pain after an athletic injury. The patient had to convince himself to visit the physician. He felt he was being a “baby” to complain. One week after the injury, he went to his family physician who perfunctorily prescribed a strong painkiller and offered a follow-up appointment a month later. He left feeling that he had been a nuisance. The following week was a particularly bad one for the patient; the pain was severe. But the patient stopped taking the prescribed medication, did not keep the follow-up appointment, and never returned for help. This patient continued to experience pain, unnecessarily, for years. In large part, this was because the physician offered no hope; therefore, follow-up care, including physical therapy and alternative medications, could not be provided. Clinical Vignette 1 A 20-year-old female patient suffered a painful athletic injury. She was unsure exactly how her injury had occurred, but she did recall falling on her shoulder on the tennis court while running after a sharply hit ball. She went to the physician fearing that she had damaged her collarbone. When she was informed that there was no fracture, that her pain was due to a bruised muscle and would go away with ice, heat, and aspirin, she immediately felt better. Not only was she relieved but also her perception and experience of the pain actually changed: “It doesn’t seem to hurt as much now”. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 34 The Psychiatric Interview Formation of the Physician–Patient Relationship Assessment and Evaluation The physician–patient relationship develops during the assessment and evaluation of the patient. The patient observes the thoroughness and sensitivity with which the physician collects information, performs the physical examination, and explains needed tests. At each step, the physician’s clarification of the treatment goals and interventions either builds up the patient’s expectation of help and feelings of safety or creates increasing disease for the patient. In many aspects, the physician’s compassion and patience establishes the context in which learning and growth may occur and anxiety decrease. Alertness to the patient’s fears and misunderstandings of the evaluation process can minimize unnecessary disruptions of the relationship and provide information on the patient’s previous experiences with medical care and important authority figures, which influence the patient’s present expectations of either help or disappointment (Table 2.1). Clinical Vignette 3 A 45-year-old single man was hospitalized for treatment of a bleeding ulcer. The patient had no past history of ulcers. Despite reassurance, he continued to feel hopeless. A psychiatric consultant was called to evaluate the patient. She found him to be needy, but could not understand why he was so pessimistic. The psychiatrist recognized how important it was to this patient for her to show interest in him, show concern for his condition, and spend time with him. The patient’s response was noteworthy; he clearly enjoyed the psychiatrist’s company but seemed unusually sad when their times together ended. The psychiatrist asked the patient if this was a correct perception and, if so, why it was the case. The patient responded that the psychiatrist reminded him of his mother. Further inquiry revealed that the patient’s mother had died several years ago of colon cancer. The psychiatrist inquired about the symptoms the mother had during her terminal illness. The symptoms were similar to the patient’s symptoms: bleeding in the digestive tract and gastrointestinal pain. The psychiatrist then understood the complex process through which the patient was feeling inordinately pessimistic. Transference was evident in his experience of each departure as an unconscious reminder of the loss of his mother. The patient’s identification with his mother (as part of managing her death) was also the source of his unspoken expectation that he, too, was dying of colon cancer. It was the pattern of the relationship between the psychiatrist and the patient, the sadness shown whenever the psychiatrist left, that provided the information necessary to help the patient. Increasing the patient’s understanding of his medical condition, specifically how it was different from his mother’s, relieved his emotional pain, and he thus began his road to recovery. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 2 • Physician–Patient Relationship 35 Rapport Early in the relationship between a psychiatrist and a patient, the patient requests help with his or her pain, uncertainty, or discomfort. The psychiatrist initiates the “contract” of the relationship by acknowledging the patient’s pain and offering help. In this action, the psychiatrist has recognized the patient’s ill-health and acknowledged the need for and possibility of removing the disease or illness. In this first stage of the development of rapport, the way of relating between the physician and the patient, the physician–patient relationship has begun to organize the interactions. Through the physician’s and the patient’s shared recognition of the patient’s pain, the basis for rapport – a comfortable pattern of working together – is established. The psychiatrist’s ability to empathize, to understand in feeling terms every patient’s subjective experience, is important to the development of rapport. Empathy is particularly important in complex interpersonal behavioral problems in which the environment (family, friends, caretakers) may wish to expel the patient, and the patient has therefore lost hope. Suicidal patients, adolescents involved in intense family conflicts, and patients in conflict with their medical caregivers can often be convinced to cooperate with the evaluation only when the psychiatrist has shown accurate empathy early in the first meeting with the patient. This rapport establishes a set of principles of and expectations for the physician–patient interaction. On this basic building block, more elaborate goals and responsibilities of the patient can be developed (Clinical Vignette 4). Table 2.1 Mechanisms for the Formation of the Physician–Patient Relationship Assessment and evaluation process Development of physician–patient rapport Therapeutic or working alliance Transference Countertransference Defense mechanisms Patient’s mental status Clinical Vignette 4 A young man sought treatment for ill-defined reasons: he was dissatisfied with his work, his social life, and his relationship with his parents. He was unable to say how he thought the psychiatrist could help him, but he knew he was experiencing emotional pain: he felt sadness, anxiety, inhibition, and loss of a lust for living. He wanted help. The psychiatrist noted the patient’s tentative style and heard him describe his ambivalence toward his controlling and directing father. With this in mind, the psychiatrist articulated the patient’s wish for help and recognized with him his confusion about what was troubling him. She suggested that through discussion they might define together what he was looking for and how she might help him. This description of the evaluation process as a joint process of discovery established a rapport based on shared work, which removed the patient’s fears of control and allowed him to feel heard, supported, and involved in the process of regaining his health. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 36 The Psychiatric Interview The Therapeutic or Working Alliance With more disturbed patients, considerable skill is required of the physician to reach this reality-based part of the patient and decrease the patient’s fears and expectations of attack or humiliation. Even for healthy patients, the physician must bridge the gap between the patient and the physician, which is always present because of their different backgrounds and perceptions of the world. This gap is an expectable result of differences between the physician’s and the patient’s culture, gender, ethnic background, socioeconomic class, religion, age, or role in the physician–patient relationship. The experienced physician makes communication across the gap seem effortless, using a different “language” for each patient. The student often sees this as an art rather than as a skill to be learned. The therapeutic alliance is extremely important in times of crisis such as suicidality, hospitalization, and aggressive behavior. But it is also the basis of agreement about appointments, fees, and treatment requirements. In psychiatric patients, this core component of the physician–patient relationship can be disturbed and requires careful tending. Frequently, the psychiatrist may feel that he or she is “threading a needle” to reach and maintain the therapeutic alliance while not activating the more disturbed elements of the patient’s patterns of interpersonal relating. The therapeutic or working alliance must endure in spite of what may, at times, be intense, irrational, delusional, characterologic, or transference-based feelings of love and hate. The working alliance must outweigh or counterbalance the distorted components of the relationship. It must provide a stable base for the patient and the physician when the patient’s feelings or behaviors may impair reflection and cooperation. The working alliance embodies the mutual responsibilities both physician and patient have accepted to restore the patient’s health. Likewise, the working alliance must be strong enough to ensure that the treatment goes forward even when both members of the dyad may doubt that it can. The alliance requires a basic trust by the patient that the physician is working in his or her best interests, despite how the patient may feel at a given moment. Patients must be taught to be partners in the healing process and to recognize that the physician is a committed partner in that process as well. The development of common goals fosters the physician and patient seeing themselves as having reciprocal responsibilities: the physician to work in a physician-like fashion to promote healing; the patient to participate actively in formulating and supporting the treatment plan, “trying on” more adaptive behaviors in the chosen mode of treatment, and taking responsibility for his or her actions to the extent possible (Ursano and Silberman, 1988). Important to the reality-based relationship with the patient is the physician’s ability to recognize and acknowledge the limitations of her or his knowledge and to work collaboratively with other physicians. When this happens, patients are most often appreciative, not critical, and experience a strengthening of the alliance because of the physician’s commitment to finding an answer. When a patient loses confidence in the physician, it is often because of unacknowledged shortcomings in the physician’s skills. The patient may lose motivation to maintain the alliance and seek help elsewhere. Alternatively, the patient may seek no help. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 2 • Physician–Patient Relationship 37 Transference and Countertransference Transference is the tendency we all have to see someone in the present as being like an important figure from our past. This process occurs outside our conscious awareness; it is probably a basic means used by the brain to make sense of current experience by seeing the past in the present and limiting the input of new information. Transference is more common in settings that provoke anxiety and provide few cues to how to behave – conditions typical of a hospital. Transference influences the patient’s behavior and can distort the physician–patient relationship, for good or ill. Although transference is a distortion of the present reality, it is usually built around a kernel of reality that can make it difficult for the inexperienced clinician to recognize rather than react to the transference. The transference can be the elaboration of an accurate observation into the “total” explanation or the major evidence of some expected harm or loss. Often the physician may recognize transference by the pressure she or he feels to respond in a particular manner to the patient, for example, always to stay longer or not abruptly leave the patient. Transference is ubiquitous. It is a part of day-to-day experience, although its operation is outside conscious awareness. Recognizing transference in the physician–patient relationship can aid the physician in understanding the patient’s deeply held expectations of help, shame, injury, or abandonment that derive from childhood experiences. Transference reactions, of course, are not confined to the patient; the physician also superimposes the past on the present. This is called countertransference, the physician’s transference to the patient (Table 2.2). Countertransference usually takes one of two forms: concordant countertransference, in which one empathizes with the patient’s position; or complementary countertransference, in which one empathizes with an important figure from the patient’s past. For example, concordant countertransference would be evident if a patient were describing an argument with his or her boss, and the psychiatrist, perhaps after a disagreement with the psychiatrist’s own supervisor and without having collected detailed information from the patient, felt, “Oh yeah, what a terrible boss”. Similarly, complementary countertransference would be evident if the same psychiatrist felt, “This person (the patient) does not work very hard, no wonder the boss is dissatisfied”, and felt angry with the patient as well. Paying close attention to our personal reactions while refraining from immediate action can inform us in an experiential manner about subtle aspects of the patient’s behavior that we may overlook or not appreciate. In the preceding example, the psychiatrist with the concordant countertransference might be identifying with the patient’s subtle need to fight Table 2.2 Types of Countertransference Concordant countertransference The physician experiences and empathizes with the patient’s emotional experience and perception of reality Complementary countertransference The physician experiences and empathizes with the emotional experience and perception of reality of an important person from the patient’s life Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 38 The Psychiatric Interview with authority. The psychiatrist with the complementary countertransference might have identified with the patient’s boss, seeing only the patient’s more passive wishes. Countertransference occurs in all “sizes and shapes”, more or less mixed with the physician’s past but often greatly influencing the physician–patient relationship. The wish to save or rescue a patient is commonly experienced and indicates a need to look for countertransference responses. When a patient is seriously ill, such as with cancer, we may increasingly want to treat the patient more aggressively, with procedures that may hold little hope, create substantial pain, and perhaps even be against the patient’s wishes. The physician’s feelings of loss of a valued person (in the present and as a reminder of the past) or feelings of failure (loss of the physician’s own power and ability) can often fuel such reactions. More subtle factors, such as the effects of being overworked, can result in unrecognized feelings of deprivation, leading to unspoken wishes for a patient to quit treatment. When these feelings appear in subtle countertransference reactions, such as being late to appointments, becoming tired in an hour, or being unable to recall previous material, they can have powerful effects on the patient’s wish to continue treatment. Major developmental events in physicians’ lives can also influence their perceptions of their patients. When a psychiatrist is expecting the birth of a child, she or he may be overly sensitive to or ignore the concerns of a patient worried about a significant illness in the patient’s child. Similarly, a physician with a dying parent or spouse may be unable to empathize with a patient’s concerns about loss of a job, feeling that it is trivial (Clinical Vignette 5). Defense Mechanisms All people, including patients, employ mechanisms of defense to protect themselves from the painful awareness of feelings and memories that can provoke overwhelming anxiety. Defense mechanisms are specific cognitive processes: ways of thinking that function in part to avoid painful feelings. They are often characteristic of a person and form a style of Clinical Vignette 5 A psychiatrist was called to evaluate an agitated older adult resident of a nursing home. After she had interviewed the energetic, sad, and anxious patient, the psychiatrist found herself unexpectedly sad, confused, and unsure about what to do. This was not a new case for the psychiatrist, who had treated many similar cases. In considering her response, her thoughts turned to her grandmother with whom she had lived when she was 8 years old, and who had been displaced from her residence and moved to a nursing home in another city by well-meaning children who wanted her near them. After the move, her grandmother had become depressed and disoriented and died 3 months later. The psychiatrist recalled feeling confused at the time of her grandmother’s death, wondering why she had died when she had just moved to an attractive new home. Recalling her confusion, the psychiatrist could think more clearly about her present patient and wondered if the patient might be depressed. She talked further with the nurses and found symptoms of depression in addition to the nighttime agitation. This new information altered her decision on the type of medication to begin with and the need for psychotherapy in addition to medication. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 2 • Physician–Patient Relationship 39 cognition. Common defense mechanisms include projection, repression, displacement, intellectualization, humor, suppression, and altruism (Table 2.3). Defense mechanisms may be more or less mature depending on the degree of distortion of reality and interpersonal disruption to which they lead. This patterning of feelings, thoughts, and behaviors by defense mechanisms is involuntary and arises in response to perceptions of anxiety or other emotional distress. The patient’s characteristic defense mechanisms, the cognitive processes used to lower anxiety and unpleasant feelings, can greatly affect the physician–patient relationship. Defense mechanisms operate all the time; however, in times of high anxiety, such as in a hospital or during a life crisis, patients may become much less flexible in the defenses they use and may revert to using less mature defenses. Clinical Vignettes 6 and 7 are examples of defense mechanisms (conversion and avoidance or repression) affecting the treatment relationship. In Clinical Vignette 6, the conversion reaction that resulted in the paralysis expressed both the patient’s anger and his conflict over what to do. In Clinical Vignette 7, the physician knew that the forgetting was neither intentional nor conscious but was directed at denying the need for treatment. In these cases, recognizing the defenses was important to knowing how to relate to the patient (Clinical Vignette 6) and avoid a countertransference reaction of anger at the patient for lack of compliance (Clinical Vignette 7). Mental Status of the Patient The patient’s mental status is a major determinant of the formation and nature of the relationship with the physician. A young, healthy patient with an acute disorder has different needs and expectations than a somewhat older person who comes for help with a condition that has been present for a number of years. Both differ from the older adult who comes to the physician expecting that the future will be filled with physical and emotional losses. Table 2.3 Common Defense Mechanisms Healthier Defenses More Primitive Defenses Sublimation Splitting Humor Projection Repression Projective identification Displacement Omnipotence Intellectualization Devaluing Reaction formation Primitive idealization Reversal Denial Identification with the aggressor Conversion Asceticism Avoidance Altruism Isolation of affect Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 40 The Psychiatric Interview Clinical Vignette 7 A 20-year-old man came for consultation because of uncertainty about his career. He soon revealed that he felt profoundly sad, hopeless, helpless, and even suicidal. He had a family history of depression. The physician and patient agreed to employ antidepressant medication aggressively. Yet, over a period of several weeks, the patient did not improve. When the physician asked why that might be happening, the patient revealed that he had frequently forgotten to take the prescribed medication and had forgotten to tell the physician that this was the case during two meetings. The physician explored the reasons for this, and together the physician and the patient learned that the patient felt ashamed of having been diagnosed as depressed and of having been considered to require medication. He felt he was not his own master and had experienced this as a severe blow to his self-esteem. Taking the medication was a reminder of this “flaw”. Hearing himself say this and feeling the physician’s empathic support, the patient recognized the irrationality of his behavior and felt relieved. In addition, the physician now understood better the intensity of the patient’s feelings and changed the prescription to once-a-day dosage at bedtime to decrease the patient’s sense of shame and increase compliance with the treatment. Clinical Vignette 6 A 36-year-old army first sergeant was hospitalized for the evaluation of acute paralysis of his right hand. When the results of a neurological workup revealed no evidence of organic pathology, psychiatric consultation was obtained. The patient denied any past psychiatric history or significant alcohol or other substance abuse. He described a healthy family support system but then hesitated, saying, “You know, Doc, there’s one thing I just haven’t been able to talk about with anyone”. He proceeded to speak of the extreme pressure he was feeling on the job, where he had found out that his boss (the company commander) was behaving unethically. The patient stated, “I feel like I’m between a rock and a hard place – if I report it, I’m being disloyal to my boss, but if I don’t, I’m betraying my soldiers and the army”. After further elaborating his feelings of anger and disgust toward his boss, the patient asked to terminate the interview but agreed to talk with the psychiatrist again in the morning. Returning the next morning, the psychiatrist was greeted by the patient, who was brushing his teeth, using his right hand. “Hey, Doc, I’m good to go!” The patient then described what happened the evening before. “I was telling my wife about how I’ve got to get out of here and get back to work, because, after all, I’m the commander’s right-hand man. And you know what, Doc? My hand started to work! Get me out of here, I’m not crazy after all!” The patient then reviewed the process, aided by the psychiatrist, and was able to further his understanding of the link between his conflicted rage toward his boss and how it was expressed symbolically as an involuntary physical paralysis of his right hand. He resolved: “I’m gonna do the right thing. I got to live with myself”, and planned to report the commander’s misconduct on return to work. He was discharged from the hospital later that day, having regained full use of his hand. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 2 • Physician–Patient Relationship 41 It can be seen when comparing these two clinical vignettes (Clinical Vignettes 8 and 9) that the mental status of the patient helps define the nature of the physician–patient relationship, though in both cases the treatment relationship was of relatively brief duration and ended successfully. Clinical Vignette 8 A 25-year-old recent law school graduate came to a psychiatrist following a romantic disappointment. He reported that he was very sad because his girlfriend had chosen to move to a different city, which he believed foretold the end of their relationship. He added that he had been having trouble sleeping for several weeks, and was worried because his exhaustion was causing problems in his ability to perform his work. When the physician took a careful history, he learned that this young man had led a successful life, and that his social and sexual development had been quite unremarkable. He had had good friends and close friendships, and several girlfriends in his life. He said he would miss his girlfriend, but that he never intended to marry her. The doctor indicated to her patient that sometimes, after such a disappointment, it was quite common for there to be a period of anxiety and that his sadness was a good sign, showing that he had a good capacity to attach and mourn the loss of a close friend. The psychiatrist also suggested that the patient may be more angry with the girlfriend than he had recognized, with which the patient agreed. The doctor prescribed a mild sleep medication, suggesting it may not even be required, and scheduled a follow-up appointment in a month. When the patient returned, he reported that he had used only two of the sleeping pills and had thrown the rest away. He did not want to schedule another appointment; he expressed gratitude to the psychiatrist and they parted company. Clinical Vignette 9 A 70-year-old widowed lawyer was vigorous, active, and financially comfortable, with many friends and professional associates. She explained to the psychiatrist that the last year had, however, been very difficult for her. Six months before, her husband of 45 years had died after a 2-year struggle with congestive heart failure. She now found herself seriously depressed, despite her active life. She was thinking actively about giving up her law practice, though she was very involved in several ongoing cases, which she had previously found interesting and which held the promise of significant financial reward. She went on to say that she had no appetite. She was chronically sleep-deprived and was losing interest in her friends, children, and grandchildren. When taking a careful history, the psychiatrist also learned that this patient had suffered from a serious depression 35 years earlier, when she lost a pregnancy, and that this depression lasted for a year. It eventually resolved after she took a tricyclic antidepressant and engaged in brief, insight-oriented psychotherapy. In that therapy, her relationship with her own depressed mother had been discussed. With all this information, the psychiatrist suggested she and her patient meet weekly and that the treatment include a pharmacological intervention to help with the patient’s current depression. This treatment ended successfully 1 year later. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 42 The Psychiatric Interview The patient’s mental status in this case was the focus of and major factor in the structure of a long psychotherapy that greatly assisted the rehabilitation of interpersonal skills and the understanding of his cognitive limitations and newly changed cognition. The ability to work with an empathic listener while confronting limitations and feelings of shame and embarrassment is a special opportunity of the well-formed doctor–patient relationship (Clinical Vignette 10). Special Issues in the Physician–Patient Relationship Phase of Treatment The treatment phase – early, middle, or late (Table 2.4) – affects the structure of the physician– patient relationship in terms of both the issues to be addressed and the task to be accomplished by the physician and the patient. The early stage of treatment involves developing a rapport, forming shared initial goals, and initiating the working alliance. Education of the patient is important to the success of the physician–patient relationship in this stage, so that the patient Clinical Vignette 10 A 40-year-old man came to a psychiatrist with a long history of emotional difficulties. He had been a healthy and happy college student when he developed a skin abscess, which caused a septicemia and a brain infection. After this, his entire life changed. Although college was quite challenging, he was able to finish it, but had difficulty concentrating, his judgment was poor, and his impulse control impaired. He had difficulty remembering words, and he realized that his previously adequate social skills had been lost. Where once he had been charming and known for his sense of humor, he was now dull and in many ways boring. Yet there was more to him than that, and he longed for an opportunity to speak with an understanding listener in the hope that through such a relationship he might be able to make constructive changes in his life. He knew what had been lost, he wanted to understand his limitations better, and he wanted to be able to function well enough to keep a job. A more remote goal was to have a long-term relationship with a woman. His consulting psychiatrist knew that were she to take on this patient, it would be for the long haul. Fortunately, there were no financial barriers to treatment, and the pair worked together on a weekly basis for many years. In the course of that treatment, the patient came to understand the social situations that made him anxious and the way his emotional states of mind influenced changes in his cognitive function. He developed the ability to work and love more effectively; he met a woman who was kind and loving. The psychiatrist was invited to his wedding. She attended the religious service but quietly left the reception after congratulating her patient and his wife. By that time, years into the physician–patient relationship, the patient saw his physician as a wise observer, an advisor, and a trusted friend. To the physician, her patient was a happy reminder of how much a person can strive to improve his life, and a rich source of learning about the interaction of emotion, cognitive function, and behavior. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 2 • Physician–Patient Relationship 43 learns what he or she can expect. In the middle stage of treatment, the physician and patient continuously refine their shared goals, and various interventions are tried. While this takes place, transference and countertransference are likely to emerge. How these are recognized and managed is critical to whether the relationship continues and is therapeutic. In the later phase of treatment, the assessment of the outcome and plans for the future are the primary focus. The physician and the patient discuss the end of their relationship in a process known as termination. Successes and disappointments associated with the treatment are reviewed. The physician must be willing to acknowledge the patient’s disappointments, as well as recognize her or his own disappointments in the treatment. The therapeutic alliance is strengthened in this stage when the physician accepts expressions of the patient’s disappointments, encourages such expressions when they are not forthcoming, and prepares the patient for the future. Such preparations include orienting the patient as to when he or she might seek further treatment. Solidifying the physician–patient relationship at the end of the treatment can be critical to the patient’s self-esteem and willingness to return if symptoms reappear (Table 2.5). As a part of the termination process, the physician and the patient must review what has been learned, discuss what changes have taken place in the patient and the patient’s life, and acknowledge together the sadness and joy of their leave-taking. The termination involves a mourning process even when treatment has been brief or unpleasant. Of course, when the physician–patient relationship has been rewarding, and both physician and patient are satisfied with what they have accomplished, mourning is more intense and often characterized by a bittersweet sadness. Treatment Settings The physician–patient relationship takes place in a variety of treatment settings. These include the private office, community clinic, emergency room, inpatient psychiatric ward, and general hospital ward. Psychiatrists treating patients in a private office may find that Table 2.4 Key Features of Treatment Phases Early: developing rapport, forming shared initial goals, initiating the working alliance Middle: refining shared goals, using a variety of trial interventions Late: assessing outcome, resolving presenting problems, planning for future Table 2.5 Factors Affecting the Physician–Patient Relationship Phases of treatment: early, middle, late Treatment setting Transition between inpatient and outpatient treatment Managed care Health and illness of the physician Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 44 The Psychiatric Interview the relative privacy of this setting enhances the early establishment of trust related to confidentiality. In addition, the psychiatrist’s personality is more evident in the private office where personal factors influencing choice of decor, room arrangement, and location play a role. However, in contrast to the hospital or community setting, the private office generally lacks other evidence of the physician’s competence and humanness. In hospital and community settings, when a colleague greets the physician and the patient in the hall, or the physician receives a call for a consultation by a colleague or for a meeting, it indicates to the patient that the physician is qualified, skilled, and humane. On the other hand, therapeutic work conducted in the community clinic, emergency room, and general hospital ward often requires the psychiatrist and patient to adapt rapidly to meeting one another, assessing the problem, establishing treatment goals, and ensuring the appropriate interventions and follow-up. The importance of protecting the patient’s needs for time, predictability, and structure can run counter to the demands of a busy service and unexpected clinical and administrative requirements. The psychiatrist must stay alert to the patient’s perspective but not all interruptions can be avoided. The patient can be informed and accommodated as much as possible, and any feelings of hurt, disappointment, or anger can be listened for by the physician and responded to empathically. At times, patients, particularly those with borderline personality disorder, may require transfer to another psychiatrist whose schedule can accommodate the patient’s exquisite needs for stability. The boundaries of confidentiality are necessarily extended in hospital and community settings to include consultation with other physicians, nursing staff, and often family members. Particular attention must always be given to the patient’s need for and right to respect and privacy. Regardless of the setting, patients receiving medication must be fully informed about the potential risks and benefits of and alternatives to the recommended pharmacological treatment. Patients must be educated about the risks and benefits of receiving prescribed treatment and of not receiving treatment. This is an important component of maintaining the physician–patient relationship. Patients who are informed about and involved in decisions about medication respect the physician’s role and interest in their welfare. Psychiatrists must also pay particular attention to the meaning a patient attaches to any prescribed medication, particularly when the time comes to alter or discontinue its use. The change from inpatient to outpatient therapy involves the resumption of a greater degree of autonomy by the patient in the physician–patient dyad. The physician must actively encourage this separation and its hope for the future. This transition is delicate for any therapeutic pair. The Physician–Patient Relationship in Specific Populations of Patients Cross-cultural and Ethnic Issues Addressing cross-cultural issues such as race, ethnicity, religion, and gender is vital to  the establishment and maintenance of an effective physician–patient relationship (see  Chapter 3). Failure to clarify cultural assumptions, whether stemming from Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 2 • Physician–Patient Relationship 45 differences or similarities in background, may impede the establishment of a trusting therapeutic alliance, making effective treatment unlikely. Children, Adolescents, and Families Establishing an effective physician–patient relationship with children, adolescents, and families is one of the most challenging and rewarding tasks in the practice of psychiatry. Rather than being treated as “little adults”, children and adolescents must be approached with an appreciation for their age-appropriate developmental tasks and needs. When physicians treat this population, they must establish a trusting relationship with both the patient and the parents. Preadolescent children face the psychosocial developmental tasks of establishing trust, autonomy, initiative, and achievement. By understanding the facets of normal childhood development, physicians may help parents understand the nature of their child’s disturbance and work within the family system to establish effective mechanisms for coping and recovery. Adolescent patients, facing the task of establishing an individual identity, pose particular challenges to the physician–patient relationship. Adolescents are particularly sensitive to any signals from the physician that their powers of decision, their intelligence, or their perceptions are being ignored. Defiance, detachment, and aggression may be anticipated and defused with a steady therapeutic presence grounded in consistent boundaries and open acknowledgment of the adolescent patient’s distress. In working with families, physicians in general and psychiatrists in particular must clearly address questions and concerns regarding all aspects of treatment and convey respectful compassion for all members. The therapeutic alliance, or “joining” with the family and patient, requires developing enough of a family consensus that treatment is worth the struggle involved. Taking sides and engaging with individual and family power struggles can be particularly destructive to the physician–patient relationship in families. Terminally Ill Patients Terminally ill patients share concerns related to the end of the life cycle. Elderly patients at all levels of health face the developmental task of integrating the various threads of their life into a figurative tapestry that reflects their lifelong feelings, thoughts, values, goals, beliefs, experiences, and relationships, and places them into a meaningful perspective. Patients newly diagnosed with a terminal illness such as metastatic cancer or acquired immunodeficiency syndrome may be particularly overwhelmed and initially unable to deal with the demands of their illness, especially if the patient is a young adult or child. Psychiatrists may enhance the terminally ill patient’s ability to cope by addressing issues related to medical treatment, pharmacotherapy, psychotherapy, involvement of significant others, legal matters, and institutional care. Patients struggling with spiritual or religious concerns may benefit from a religious consultation, a resource that is frequently unused. Countertransference feelings ranging from fear to helplessness to rage to despair can assist the therapist greatly in maintaining the physician–patient relationship and ensuring Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 46 The Psychiatric Interview appropriate care. Issues commonly encountered with disabled patients include inaccurate assumptions about their ability to function fully in all areas of human activity, including sex and vocation. Terminally ill patients may evoke reactions of unwarranted pessimism, thwarting the physician’s ability to help the patient maximize hope for the quality of  whatever time may remain. Patients and their family members often look to their physician for guidance. Conclusion The physician–patient relationship is essential to the healing process and is the foundation on which an effective treatment plan may be negotiated, integrating the best of what medical technology and human caring can provide. The centrality of this relationship is particularly true for psychiatric physicians and their patients. In the psychiatrist–patient relationship, empathy, compassion, and hope frequently serve as the major means of alleviating pain and enhancing active participation in all treatment interventions: biological, psychological, and social. The development of the physician–patient relationship depends on skilled assessment, the development of rapport through empathy, a strong therapeutic alliance, and the effective understanding of transference, countertransference, and defense mechanisms. Current research findings support the purposeful use of common therapy factors, of which the therapeutic alliance is the most powerful, to enhance clinical outcome. The development of the physician–patient relationship is influenced by numerous factors, including the phase of treatment, the treatment setting, transitions between inpatient and outpatient care, managed care, and changes in the physician’s health. The astute physician is attuned to the needs and characteristics of specific populations of patients, adopting the therapeutic approach that most effectively bridges the gap between physician and patient and leads to a healing relationship. References Petrovic P, Kalso E, Petersson KM et al. (2002) Placebo and opioid analgesia – Imaging a shared neuronal network. Science 295, 1737–1740. Ursano RJ and Silberman EK (1988) Individual psychotherapies, in The American Psychiatric Press Textbook of Psychiatry (eds Talbott JA, Hales RE and Yudofsky SC). American Psychiatric Press, Washington, DC, pp. 876–884. Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 14:15:49. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.